Dr. Jun Xu went to Leprosy village in 2013, 2014 and 2016, soon he will go to the leprosy village on March 31, 2017.

In 2013, there was no a single room being used for treatment in the leprosy village, Dr. Xu and his team had to use a tent. The temperature was around 125 Fahrenheit degrees.

The leprosy patients were waiting for their turn to be attended. Dr. Jun Xu saw about 200 patients a day.

Typical leprosy patient:
Early Stages
Spots of hypopigmented skin- discolored spots which develop on the skin
Anaesthesia(loss of sensation) in hypthese opigmented spots can occur as well as hair loss
“Skin lesions that do not heal within several weeks of and injury are a typical sign of leprosy.” (Sehgal 24)

Progression of disease

“Enlarged peripheral nerves, usually near joints, such as the wrist, elbow and knees.”(Sehgal 24)
Nerves in the body can be affected causing numbess and muscle paralysis
Claw hand- the curling of the fingers and thumb caused by muscle paralysis
Blinking reflex lost due to leprosy’s affect on one’s facial nerves; loss of blinking reflex can eventually lead to dryness, ulceration, and blindness
“Bacilli entering the mucous lining of the nose can lead to internal damage and scarring that, in time, causes the nose to collapse.”(Sehgal 27)
“Muscles get weaker, resulting in signs such as foot drop (the toe drags when the foot is lifted to take a step)”(Sehgal 27)

Long-term Effects
“If left untreated, leprosy can cause deformity, crippling, and blindness. Because the bacteria attack nerve ending, the terminal body parts (hands and feet) lose all sensations and cannot feel heat, touch, or pain, and can be easily injured…. Left unattended, these wounds can then get further infected and cause tissue damage.” (Sehgal 27)
As a result to the tissue damage, “fingers and toes can become shortened, as the cartilage is absorbed into the body…Contrary to popular belief, the disease does not cause body parts to ‘fall off’.” (Sehgal 27)

Every year, Dr. Jun Xu and his team bring around $300,000 worth of medicine donated from his team members and Americares in Stamford, CT to treat the leprosy and other patients in Senegal and Guinea Bissau. http://www.americares.org/, in 2017, his team also received medicine donation from Direct Relief in California, https://www.directrelief.org/.
Dr. Jun Xu and his team finally established a clinic in the leprosy village, one building for the clinic, and another building for the living of doctors and nurses.

Leprosy village people were celebrating the opening of the clinic.

There are 8 wards, which could hospitalize the patients if it is medically necessary.

Dr. Jun Xu’s team usually stay in Senegal for 10 to 14 days, these are the foods his team brought from US in order to keep them health and safe. They do not dare to eat street food.

The above are the coolants contained food Dr. Jun Xu’s team brought from US

Dr. Jun Xu and his team from US in 2006.
If you are interested in joining Dr. Jun Xu’s team or donating to his work in Senegal, please address your check payable to AGWV, and send to
Jun Xu, MD, 1171 E Putnam Avenue, Riverside, CT 06878, USA.
Dr. Xu promises that all your donation 100% will go to Senegal and his team will nerve use a penny from your donation. You will receive the tax deductible receipt. Any amount is a great help for Africa patients.
For more info, please visit our websites at
http://www.drxuacupuncture.co/ and http://www.africacriesout.org/

Sandy, a 45 year-old woman, complained of bilateral hand and wrist pain on-and-off for many years. Recently for a month now, she felt both hands had constant pain and were tender, warm and swollen. She woke up with morning stiffness that may last for hours and felt firm bumps of tissue under her both forearm accompanied with fatigue, mild fever and gradually weight loss. She visited her PCP and was given naproxen to reduce her inflammation and pain, however, she felt no improvement. She was referred to a rheumatologist, who ordered x-ray images and rheumatoid factor test. Both were positive for Rheumatoid Arthritis, therefore, the diagnosis was confirmed. The patient was given methotrexate and felt better for morning stiffness and swelling, however, she had many side effects, such as, nausea, vomiting, hair loss, etc. Because of above complaints, she came to me for evaluation and treatment.

Rheumatoid Arthritis (RA) is a chronic, long-term disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs. As the disease progresses, symptoms often spread to the knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.

The stiffness seen in active RA is most often worst in the morning. It may last one to two hours (or even the whole day). Stiffness for a long time in the morning is a clue that you may have RA, since few other arthritic diseases behave this way. For instance, osteoarthritis most often does not cause prolonged morning stiffness.

The normal joint structure appears on the above left. On the right is the joint with rheumatoid arthritis. RA causes synovitis, pain and swelling of the synovium (the tissue that lines the joint). This can make cartilage (the tissue that cushions between joints) and bone erode, or wear away.

RA is an autoimmune disease. This means that certain cells of the immune system attack healthy tissues — the joints in RA, cause the inflammation in the synovium, the tissue that lines the joint. Immune cells release inflammation-causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone.

Rheumatoid arthritis affects the wrist and the small joints of the hand, including the knuckles and the middle joints of the fingers.

Fig. 3 RA Hand Deformity www.eastlady.cn

Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.

Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. Telltale signs include:

Anemia (a low red blood cell count)

Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)

Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70% of patients with RA)

Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

X-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.

There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.

There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime. The treatment must start as earlier as possible.

A goal of physical therapy is to help make the muscles stronger and the improve the motion of the joints. Warming up painful joints is very important in managing pain and priming the body for more exercise. This can be accomplished with moist heating pads, a whirlpool or warm shower. Following the warm-up, aerobic exercise such as a stationary bike, elliptical, or even arm bike will continue to work the body. Other arthritis friendly options are aquatic exercises, tai chi or yoga routines.

It is important to be flexible with the workout routine, as if after the warm-up and aerobic exercise the joints are still very sore, change to strengthen a body part with less discomfort. However, do not get in a habit of skipping the warm-up and light aerobic exercise if a joint is tender, as often just these two steps will greatly improve how the joint is feeling. Below are a few range of motion and light strengthening exercises to help the hand that can be performed daily.

Good control of RA requires early diagnosis and, at times, aggressive treatment. Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever. DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA.

Common DMARDs include methotrexate (brand names include Rheumatrex® and Folex®), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Older DMARDs include gold, given as a pill — auranofin (Ridaura) — or more often as an injection into a muscle (such as Myochrysine). The antibiotic minocycline (e.g., Minocin, Dynacin and Vectrin) also is a DMARD, as are the immune suppressants azathioprine (Imuran) and cyclosporine (Sandimmune and Neoral). These three drugs and gold are rarely prescribed for RA these days because other drugs work better or have fewer side effects.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. These medications are also DMARDs. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.

The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care requires the expertise of a team of providers, including rheumatologists, primary care physicians, physiatrist and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.

Living with rheumatoid arthritis

It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.

When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.

Acupuncture Treatment:

Acupuncture is an excellent alternative way to treat your symptoms. It has no side effects and can be combined with traditional western medicine to relieve your symptoms. The choice of acupuncture treatment of RA is as following,

Sandy was treated with me for 2 x per week for 8 weeks. I first try to decrease her pain at the joints and body with the points of group 1 and 2 , then, I used the group 3 and 4 points to help her to improve her fatigue and depression, after about 2 month’s treatment, Sandy was put on maintenance treatment program once a week for 4 weeks, and she felt much improved. Her pain scale decreased from 7/10 to 2/10. Her swelling at both hands is much relieved.

Tips for Patients:

1. Multiple Therapies are the best way to treat RA with combination of medicine, PT and Acupuncture.

2. Newer treatments are effective. RA drugs have greatly improved outcomes for patients. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.

3. Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. A physiatrist who is an expert in RA also can design a customized treatment plan that is best suited for you. Therefore, the rheumatologist, working with the primary care physician and other health care providers, should supervise the treatment of the patient with RA.

4. Start treatment early. Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

Tips for Acupuncturists:

1. Treat your patients as a whole person and long-term treatment is necessary. You should encourage your patient perform exercise, which will keep your patients’ mobility of hands and other joints.

2. Encourage your patients to have at least 8 weeks treatment. It is very important to have a long-term treatment to achieve the best results.

Helen is a 46 years old female, who complains of pain all over the body for about one year. Her husband lost his job about one year ago and has tried his best to find one. However, he has had no such luck. Helen started to worry about her family financial situation and very often could not sleep well. She always feels sluggish as sleep is not replenishing her energy. She wake up feeling very stressed out and moody and worrying about everything. She gradually developed pain all over the body, feeling tenderness at symmetric points, such as neck, upper back, shoulders, elbows, middle back, low back, hip, knee and calf. The pain is getting worse, now even moderate touch could make her feel pain. She was forced to move out of her house because she was unable to pay her mortgage and moved in an apartment recently. This made her symptom worse, she went to her primary care physician, who checked her blood work, chest x-ray and EKG, all were normal, and prescribed Ambien and pain medication, such as Oxycodone, she felt temporarily relief, however, she had constipation, headache, sometimes diarrhea, felt very tired when waking up. Because the symptoms were getting worse, therefore, she came to me for evaluation and treatment.

Upon examination, she looked very tired and fatigue, spoke with a low tone, she was found to have many tender points along the spine, chest ribs, shoulders, elbows, hips and knees, when she was touched by my fingers.

This patient might have fibromyalgia, a common syndrome, most often occurring in middle age women. Symptoms are long-term, body-wide aches, pains and tenderness. Typically symmetric in the joints, muscles, tendons, and other soft tissues, very often with accompanying fatigue, depression, insomnia, and anxiety.

Causes

The cause is unknown. Possible causes or triggers of fibromyalgia include:

Genetics: the mode of inheritance is currently unknown, but it is common to see patients in one family, especially mother and daughter.

Stress: an important precipitating factor, Fibromyalgia is frequently found with stress-related disorders, such as chronic fatigue syndrome, posttraumatic stress syndrome, irritable bowel syndrome, and depression.

Physical or emotional trauma

Poor sleep.

Among the above possible causes, the most important are stress and poor sleep, stress and poor sleep make a noxious cycle: Stress causes poor sleep, poor sleep enhances stress, both stress and poor sleep make muscles unable to relax, for a long time period, the muscles nerve get chance to relax, then it twists together and forms the tender points and bends, which are symmetric and long term.

Fibromyalgia patients tend to wake up with body aches and stiffness, pain improves during the day and gets worse at night. Some patients have pain all day long. Pain may get worse with activity, cold or damp weather, anxiety, and stress.

Fatigue, depressed mood, and sleep problems are seen in almost all patients with fibromyalgia. Many say that they can’t get to sleep or stay asleep, and they feel tired and stiffness when they wake up.

The new criteria keep the requirements that other causes be ruled out and that symptoms have to have persisted for at least 3 months. They also includes 2 new methods of assessment, the widespread pain index (WPI) and the symptom severity (SS) scale score.

The WPI lists 19 areas of the body and you say where you’ve had pain in the last week. You get 1 point for each area, so the score is 0-19.

This next part is really interesting to me. Instead of looking for a hard score on each, there’s some flexibility built in, which recognizes the fact that fibromyalgia impacts us all differently, and that symptoms can fluctuate.

For a diagnosis you need EITHER:

WPI of at least 7 and SS scale score of at least 5, OR

WPI of 3-6 and SS scale score of at least 9.

Treatment

The goal of treatment is to improve impaired function, help a person mentally and physically cope with the symptoms, and to help relieve pain and other symptoms,

Physical Therapy is aimed at treating the disease consequences of fibromyalgia including pain, fatigue, deconditioning, muscle weakness and sleep disturbances among others.

Modalities such as ultrasound and TENS machines will help reduce localized and generalized musculoskeletal pain in fibromyalgia patients.

Massage is great to reduce muscle tension and spasms which prevent efficient muscle motion. Techniques such a joint mobilizations and deep tissue massage prescribed with other therapeutic interventions such as stretching will help your muscles more effectively.

Physical Therapy consult is very beneficial to address sleeping disturbances affecting about 80% of all patients. Positioning while sleeping and relaxation techniques prior to sleeping can help correct this serious problem.

Fitness machines such as exercise bikes or elliptical machines will improve important measures of cardiovascular fitness, subjective and objective measures of pain. Also improving is subjective energy levels, work capacity along with physical and social activities.

Focusing on core stability will reduce overloading of the muscle system by supporting the muscles of your spine. There is a great impact on conditioning weak muscles for improving postural fatigue and positioning. With a strong core, your body will have a stable, center point.

There is great evidence based research for Whole Body Vibration use on patients with fibromyalgia. A 6-week study published in 2008, in The Journal of Alternative and Complementary Medicine, by Alentorn-Geli et al reports that WBV safely reduces pain and fatigue while also improving physical function in patients with fibromyalgia. Here at Rehab Medicine & Acupuncture Center, we have been using this evidence based device in successfully treating symptoms of fibromyalgia.

Another study looking at the benefits of WBV with fibromyalgia performed by Sanudo et al in 2010 was published in Clinical and Experimental Rheumatology. This study examined women with fibromyalgia performing exercise training 2 times a week along with WBV three days a week compared with an exercise only group over a 6-week period with a focus on strength and quality of life. Significant improvements in all outcomes measured were found from baseline in both groups though additional health benefits were observed with the supplementary WBV.

The second line of treatment is medications, such as antidepressant or muscle relaxant in order to improve sleep and pain tolerance, Duloxetine (Cymbalta), Pregabalin (Lyrica) and Milnacipran (Savella) are very often prescribed.

However, many other drugs are also used to treat the condition, including:

Anti-seizure drugs

Other antidepressants

Muscle relaxants

Pain relievers

Sleeping aids

Cognitive-behavioral therapy is an important part of treatment. This therapy helps you learn how to:

Helen underwent our treatment about 3 months. I first helped her improve her sleep. According to Chinese Medicine, the key factor was sleep, if the patient can have better sleep, her noxious cycle will be broken, and along with her improvement of sleep, her muscles was gradually relaxed and her pain was gradually reduced. She also was encouraged to have physical therapy to improve her functional abilities and join the entertainment activities, she had difficulty playing tennis at beginning, after a few treatments, her performance of tennis was getting better, and after all the treatment for three months, her pain is almost gone and quality of life is much better.

Tips for patients:

Keep a peaceful mood, and you have to realize that your worrying does not take away your stress, but adds stress to you.

Try to get a good sleep nightly, take hot shower before go to bed and avoid TV in order to have a nice sleep routine.

Massage sleep points 5 mins before you go to bed.

Force yourself to attend the entertainment activities

Tips for Acupuncturists:

Try to help patients to have good sleep by selecting Baihui, An Mian, etc.

Try to help patients to have stress reduction by selecting Shen Men, Shen Shu, etc.

Cindy is a 64 year-old female who complains of right hip pain for about six months after a fall in her garage and injury of her right hip. She felt immediate pain at right hip. Then, she put ice pack on the hip and took some Tylenol and Advil. She thought the pain would go away. However, after one month, the pain still was very severe and she had difficulty walking. She was unable to lie on the right side because of the pain, which always awakened her up during the night. Whenever she tried to walk, run, or lift some weight such as 10 to 20 pounds, her right hip was very painful with right leg weakness. The pain sometimes also radiated down to her knee but not below the knee. She then called her primary care physician, and an x-ray was done, which showed no bone spur, no fracture, and no osteoarthritis, and while the PCP examined her, her hip was swelling and slightly warm. The range of motion of her right hip was slightly limited. Her PCP told her it was soft tissue injury, it would get better in about one month. She was prescribed Naproxen. However, the pain is getting worse and worse. Now, she is limping and leaning to the right side. The pain interferes her daily activities such as driving, walking, lying on right side, etc. Therefore, she comes to me for evaluation and the treatment.

Physical Examination: Cindy is moderately obese and tall. She walks with a cane because the pain is so severe, she could not walk independently. I palpated her right hip joints which is swollen and very tender. The pain also goes along the right side lateral thigh. I checked her range of motion. At this time, the range of motion is slightly limited especially at the external rotation. I asked her to flex and external rotate her hip by pushing my hand resistant outward, she feels excruciated pain. Her right hip joint muscle seems weak. By sensation examination, her both legs are equal to the pinprick and light touch. There is no sensory deficit.

Because of the severe right hip pain and debilitating, I decided to order MRI. The MRI only showed the trochanteric bursa was swollen, tender, and increased in size. There is no any other tendonitis or arthritis.

This patient most likely has hip bursitis, i.e., trochanteric bursitis. On the hip, we have two trochanteric bursae, one is called superficial trochanteric bursa which is on top of the femoral head, i.e., outside the hip joint. The other one is called deep trochanteric bursa, a deep bursa, which is underneath the gluteus medius muscle. Hip bursitis are inflamed conditions of hip bursa. The patients with hip bursitis typically complain lot of hip pain, although the hip joint itself is not involved. The pain very often radiates down to the lateral aspect of the thigh.

The course and risk factors of hip bursitis: The hip bursitis usually is caused by contusions from falls, contact sports, and/or by the bursal irritation resulting from friction by the iliotibial pain (ITB).

this condition is most common in the middle aged or elderly, and especially prevalent among women with the following conditions:

Repetitive activity such as stair climbing, bicycling, standing, running, hiking for long periods of time.

An injury such as a fall, or lying on the side for long periods of time, exerting unnecessary pressure on the hip.

Lower back pain, caused by arthritis, scoliosis, spondylosis, etc.

Previous surgery, such as surgery around the hip or total hip replacement which can irritate the bursa and cause bursitis.

Leg length discrepancy. This will change the center of gravity and cause irritation of the hip bursa.

for example, which is repetitive and cumulative irritation. Sometimes, leg length discrepancy and lateral hip surgery also can cause hip bursitis.

The symptoms of hip bursitis include:

Hip pain. The pain sometimes radiates to the outside of the thigh to the knee area, as well as to the groin area. The pain may be worse during activities such as running or sitting with the leg crossed over the opposite knee.

The pain may disturb sleep, especially when the patient is lying on her right side.

Swelling may occur from the increased fluid within the bursa.

The condition may cause limping and the patient may have difficulty walking or running.

Heat and redness may occur on the affected bursa.

Hip bursitis usually is not related to osteoarthritis. Therefore, by the MRI or x-ray, you cannot see the hip spur, bone spur, or narrowing of the joint space. You may also not see the tendonitis around the hip joint and only see inflamed enlarged bursa. The differential diagnosis of hip bursitis is as following:

Fracture of the femoral head

Avascular necrosis of the femoral head

hip fracture

Lumbosacral radiculopathy

Iliopsoas tendonitis

ITB tendonitis

Internal snapping hip and external snapping hip, etc.

Western Medicine Treatment:

Most often, physician will prescribe anti-inflammatory medication such as naproxen, Advil, etc. Usually, there is no significant improvement after taking the naproxen, etc., because the bursitis is acute and severe inflammation on the bursa of the hip but many patients like to take anti-inflammatory medication.

Rehabilitation program by physical therapy. Very often, physical therapy should be applied by stretching of the ITB, tensor fascia lata, external hip rotators, quadriceps, and hip flexors. The physical therapy modality such as cold pad, electrical stimulation, and soft tissue massage might be also helpful.

Fig 12.3

Fig 22.4

Corticosteroid injection. There are many studies which showed the corticosteroid injection at the inflamed bursa can have quick, specific, and effective treatment with prolonged benefit. Usually, the patient should lie on the unaffected side. About 40 mg to 80 mg corticosteroid with 5 cc of 1% to 2% of lidocaine mixed to inject to the bursa about 66% of patients at a followup visit at one year and five years feel much improved.

As an acupuncturist, we should do as the following

Have the patient to rest. Instructed the patient do not perform any repetitive activity for at least one month, and in the meantime, put ice massage on the hip about 15 minutes to 20 minutes twice a day on the hip and the ITB. Because the inflammation inside the hip bursa, the fluid very often leaks out followed the ITB and makes the ITB inflammation. That is why, the pain radiates down to the lateral thigh. Because of ITB is attached around the knee, the pain will not go down beyond the knee. Therefore, the massage with ice is a very important procedure to decrease the inflammation and pain.

On the dorsum of the foot, in the depression distal to the junction of the first and second metatarsal bones.

Headache, dizziness and vertigo, insomnia, congestion, swelling and pain of the eye, depression,, infantile convulsion, deviation of the mouth, pain in the hypochondriac region, uterine bleeding, hernia, enuresis, retention of urine, epilepsy, pain the anterior aspect of the medial malleolus

Fig 22.5

I choose the big diameter needle and with electrical stimulation at the bursa and the big needle usually can make the swelling going down and increase the energy flow go through the bursa. The stimulation can repetitively stimulate the bursa making the patient pain sensitivity going down and the patient will tolerate more the stimulation and the daily activity. Other points such as Hegu and Taichong will increase large dosage of endorphin secretion which will make the patient feel less pain.

Cindy underwent my treatment for about 10 visits and with soft massage, ice, and acupuncture with electrical stimulation and she feels much better after the treatment. She followed up once after two months and her hip pain is completely gone.

Tips for Acupuncturist:

Always ask the patient to rest and ice massage, and if you understand some Chinese herb, you can choose some Chinese herb cream with anti-inflammation function to massage the patient’s hip and ITB.

If the patient’s hip has obvious severe inflammation or infection, do not treat and you should refer the patients to her or his primary care physicians to check if there is any infection.

A large diameter needle with electrical stimulation will be much more effective than the small diameter needle without electrical stimulation.

You may teach the patient to stretch the right ITB band and hip joints in a certain way.

Tips for Patients:

Not all the physicians can make a clear diagnosis about hip trochanteric bursitis. You have to consult physicians of orthopedics and physiatrists.

Ice massage is very important treatment method, you must use ice to massage your hip 15 min 2x a day in order to reduce the inflammation and decrease pain.

Luke L, a moderate obese, 45-year-old male had pain in his right hip for five years. The pain was of gradual onset and it sometimes radiates down through his right groin and right lateral thigh. He feels stiff and tight, and has difficulty walking and climbing the stairs. When in college, Luke was a football player, and now he still plays a lot of tennis and running. He sometimes felt pain in his right hip, however, he did not pay much attention to it. Over the last five years, the pain has intensified and recentlybecomes worse, to the extent of disturbing his sleep and limiting him to the point where he could only walk for a short distance.

He first consulted an orthopedic doctor who ordered an X-ray, which showed the joint space was narrowing with bone spur and subchondral sclerosis.

His doctor told him this was typical osteoarthritis of the hip, and, because the pain was so severe, Luke was given one steroid injection right away. He felt better for two months, but the effects of the shot wore off and the pain once again became worse. He returned to his orthopedic doctor and received second steroid injection. His orthopedic doctor told him that he probably needed a total hip replacement. As Luke is only 45 years old, he is reluctant to have the hip replacement, therefore, he consulted me.

On examination, I noticed when he walked he had a short swing of his right leg and he only could bear his weight on right leg with very short time, the short swing and stance phase on the affected side is called antalgic gait. In checking his range of motion, there appeared to be decreased external and internal rotation of the hip and the pain is elicited on the range of motion. An X-ray confirmed that Luke had severe osteoarthritis of the right hip.

There are different causes for hip osteoarthritis, however, the most common cause is secondary (i.e. from an injury).

Primary osteoarthritis is aging related osteoarthritis. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. After a certain period, the water content might also “dry out” after the cartilage gradually disappears, eventually, cartilage begins to degenerate by flaking or forming bone spurs. In advanced cases, there is a total loss of cartilage cushion between the bones of the joints.

Secondary Osteoarthritis, i.e. the Repetitive use of the worn joints over the years, such as runners, tennis players, mountain climbers and martial art performers, etc, can irritate and inflame the cartilage, causing joint pain and swelling. Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (bone spurs, also referred to as osteophytes) to form around the joints. Osteoarthritis occasionally can develop in multiple members of the same family, implying a hereditary (genetic) basis for this condition. The following are the secondary causes of hip osteoarthritis

1. Sports or other sports-related injuries such as Luke’s – who was a marathon runner, who spent much time running– gradually changed the alignment of the hip and eventually leads to wear and tear on the joint surfaces.

2. Avascular necrosis. Many patients who drink alcohol excessively, and undergo steroid injections at the hip joint or took oral steroid for long period of life time, such as Lupus, or organ transplant recipients, might experience this condition, avascular necrosis is a death of the femoral head without sepsis. This is caused by interruption of the vascular supply to the femoral head. Luke had two such injections, which may have caused worsening of the hip osteoarthritis and possible avascular necrosis.

3. There are other causes, such as obesity, trauma, surgery, gout, diabetes and high uric acid, all of which can cause osteoarthritis.

Fig 3.1

Treatment of osteoarthritis depends on the stages of the condition and the age of the patient.

In the early stages, the following are indicated:

1. Weight reduction and the avoidance of activities that exert excessive stress on the joint cartilage. For Luke this meant he needs to lose 30-40 pounds (he lost 35) and stop playing tennis and running. Instead he was encouraged to peddle a stationary bicycle and swim. He rode his bike about 45 minutes a day and swam 3-4 times a week, and these activities, plus the weight he lost, put much less strain on his hip.

2. Anti-inflammatory medications such as aspirin, acetaminophen and naproxen, also anti-inflammatory lotions, dicolfenac and pain patch, Flector may help to decrease pain.

3. Injections: Hyaluronic acid injection is a chemical which can work by temporarily restoration of the thickness of the joint fluid and allow better joint lubrication and impact capability. Steroid injections can decrease the inflammation, thereby decreasing the pain of the joint.

Ultrasound machine may clearly identify the space of the hip joint and your physician can easily insert the needle into the hip joint and make an accurate injection at the hip joint under the guidance of ultrasound machine. Therefore, if you consider an injection of the hip joint, you should ask your physician if he or she uses the ultrasound guided technique.

Fig 3.2

4. Physical therapy:

4-way Hip Exercises on Mat

Start off with 3 sets of 10 reps for 30 reps total. Next session try 2 sets of 15 reps, then after that session try 1 set of 30 reps. Continue to progress by adding an ankle weight such as 2.5# and work up again from 3 sets of 10, 2 of 15 to 1 of 30, finally progressing to a 5# ankle weight and repeat the repetition cycle.

Hip Flexion involves lying on your back with one knee bent and the working leg straight being lifted up to the height of the opposite knee than down slowly.

Hip Extension involves lying on your stomach and lifting one leg up about 10-12” then down slowly.

Hip Abduction and Hip Adduction both involve lying on your side. Hip Abduction involves the top leg being lifted up around 20” then down slowly. Hip Adduction involves crossing the top leg over the bottom leg and performing the exercise by lifting the bottom leg off the table about 10” then down slowly.

After building the strength to perform 5# for 30 reps continue to progress by performing the 4-way Hip Exercises Standing with a TheraBand working the same repetition scheme. Performing these exercises in standing offers numerous benefits; from closely mimicking functional activities of daily living to improving balance. You can have a chair for support, but gradual try not to hold on to it. By not holding the chair you will feel the additional benefit of the stabilizing muscles around the hip that is supporting the body being worked; as well as the leg with the TheraBand performing the movement.

The first two pictures shown are Hip Flexion then Hip Extension. The following two are Hip Abduction then lastly Hip Adduction Exercises.

Another two great exercises to include both help improve rotation in the hips are the Clam Shell and the Seated External Rotation Exercise. The Clam Shell can easily be performed with the 4-way Hip Exercises on the Mat. In this movement keep the feet together but rotate the top knee up then down slowly. A weight or TheraBand can easily be added to increase the difficulty of the movement.

5. Arthroscopy. Arthroscopy of the hip is a minimally invasive, outpatient procedure that is relatively uncommon. The doctor may recommend it if the hip joint shows evidence of torn cartilage or loose fragments of bone or cartilage.

6. Osteotomy. The procedure involves cutting and realigning the bones of the hip socket and/or thighbone to decrease pressure within the joint. In some people, this may delay the need for replacement surgery for 10 to 20 years. Candidates for osteotomy include younger patients with early arthritis, particularly those with an abnormally shallow hip socket (dysplasia).

In late stage of hip osteoarthritis, the following is indicated:

Following the progress of osteoarthritis of the hip, when the patient has pain even at rest and difficulty walking upstairs, it is recommended that the patient use a cane and consult a surgeon about replacement of the hip joint. Total hip replacement is now performed almost as a matter of routine, which can bring dramatic pain relief and improved function. The followings are the surgical options of hip replacement.

1. Hemi-Arthroplasty

Fig 3.7

From: http://www.eorthopod.com/content/hemiarthroplasty-hip

As its name implies, hemi, or “half” of an arthroplasty. This procedure is usually performed as treatment for a hip fracture. The femoral head, due to irreparable damage to the blood supply, yet the patient’s acetabulum (socket) is in good condition, and not in need of a prosthetic cup implant.

The fractured femoral head is removed, a corresponding head implant is inserted into the remained femur bone canal, reamed to accommodate a prosthetic stem. These parts are either cemented into place, or “press-fit” to stimulate bone in-growth into the prosthesis. It is a very stable combination, and allows for early mobilization of the typical elderly patient to reduce the risks of other medical complications.
2. Traditional Hip Replacement

Traditional total hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip in order to dislocate the hip joint.

Once the joint has been opened up and the joint surfaces exposed, the ball at the top of the thigh bone, or femur is removed. A cup-shaped implant is then pressed into the bone of the hip socket. It may be secured with screws. A smooth plastic bearing surface is then inserted into the implant so the joint can move freely.

Next, the femur is prepared. A metal stem is placed into the femur, or the thigh bone, to a depth of about 6 inches. A metallic ball is then placed on the top of the stem. The ball-and-socket joint is recreated. The stem implant is either fixed with bone cement or is implanted without cement. Cementless implants have a rough, porous surface. It allows bone to adhere to the implant to hold it in place.

2. Minimally Invasive Hip Replacement

Fig 3.9

http://www.cleburneorthopedics.com/hip_replacement.html

Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions. Candidates for minimal incision procedures are typically thin, young, healthy individuals. The artificial implants used for the minimally invasive hip replacement procedures are the same as those used for traditional hip replacement. You should consult your orthopedic doctor for the possibility of this particular procedure. The benefit of the procedure are less pain, shorter hospital stay and better cosmetic and faster rehabilitation.

Treatment by traditional Chinese medicine:

Acupuncture must be combined with the above treatment to get better results. Acupuncture, as other treatments, can not prevent the arthritis develop further, however, acupuncture can dramatically decrease arthritic pain, decrease the swelling and inflammation, and effectively delay the surgical procedure.

There are two types of pathology of hip arthritis as per Traditional Chinese Medicine:

Cold stasis: the typical symptoms are hip pain when the weather gets cold, windy or rainy. Many patients said: “ I do not need the weather man, I know it will be rainy or snow”. This is because the patients’ defensive system is not strong enough, weather changes make skin and joints sensitive, therefore, the invasive pathogens will be easier to get into the joints and make the joints stiff and pain.

Luke underwent my treatment so his pain temporarily decreased and the goal for this patient was to delay the total hip replacement procedure as long as possible. Therefore, Luke swims, rides his stationery bike and continues his weight loss, all of which put off the necessity of an operation for another two or three years.

Tips for patients:

1. Osteoarthritis of the hip is a progressive inflammation of the hip, for which there is no cure. Acupuncture can help – with other treatments –in delaying and decreasing the pain, however, the progress of worn cartilage is unpreventable.

2. For patients in their fourth or fifth decades, total hip replacement should be delayed as long as possible, because the mechanical joints usually last only about 15 years. If the patient undergoes this procedure too soon, you will expect to have it repeated in a decade and a half, so it would be best to put it off as long as is feasible. A second operation might increase the risks for surgery and its side effects.

3. Weight loss, swimming and peddling a stationery bicycle are the keys for the patient to help yourself. The patients should not perform the sports with high impact on the hip, such as running, jumping, etc.

Tips for acupuncturists:

1. There are many hip diseases that also cause pain, such as greater trochanteric bursitis, piriforms syndrome, iliopsoas bursitis and tendonitis, avascsualr necrosis of the femoral head and hip fractures, so it is important to properly differentiate among all the forms of hip pain.

2. You must differentiate the cold type from the hot one, because the treatments are different.